Although mental health awareness and understanding are high in countries around the world, stigma and discrimination are still prevalent.

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THURSDAY, March 14, 2013 – When Maria Yerema was diagnosed with clinical depression in the late 1990’s, she made the decision not to hide it—even though there was a prevailing belief that people who are mentally ill end up in institutions.

“The whole ‘mental illness’ label still kind of had the 'One Flew Over the Cuckoo’s Nest' attachment,” says Yerema, who at the time was manager of 15 stores in a large retail chain. “No one talked about it, and there was no awareness of how common it was, and no understanding of what the diagnosis meant. Today people are much more aware. There isn’t so much shame attached to the diagnosis. There is more understanding that it is an illness not a personality trait.”

Although the world is now more educated and often aware that mental illnesses are treatable and manageable, the stigma that Yerema recognized in the nineties is still a serious problem for people with mental illness around the world.

A multi-nation study released today, in a historic stigma-focused issue of the American Journal of Public Health, revealed that across cultures there are aspects of mental health that formulated a universal “backbone” of stigma. This study organized researchers from 16 countries—including the United States, Germany, Spain, Great Britain, Hungary, Bulgaria, Bangladesh, Cypress, South Korea, Iceland, the Philippines, New Zealand, and South Africa—and it looked at stigma related to depression and schizophrenia from the point of view of each particular culture.

“We had two sets of findings,” says Bernice A. Pescosolido, PhD, principle investigator of the study and lead author of The Backbone of Stigma: Identifying the Global Core of Public Prejudice Associated with Mental Illness. “We wanted to know how high the level of knowledge in terms of recognition that there were mental health issues, that treatment was available and should be sought. And the really good news is that across the countries the level of this kind of mental health literacy is quite good. So that message has been received.”

“But in terms of prejudice and discrimination, there are still these issues,” she says. “It turns out there are five kinds of issues, no matter what country you are looking at and they include things about workplace, marrying into the family, having an authority position, teaching children, and other jobs where people will be concerned a person with a mental illness would be unpredictable,” she says. “The irony is that we probably so work closely on the job with people who have mental health problems. We probably do have people in our families with this. But they don’t disclose, for the very reason that we are documenting in the study: They are afraid of the response of others to them once they have that label or mark of mental illness.”

Stigma is not just a sense of shame or hiding a condition. It impacts cultures in numerous ways, says Dr. Pescosolido:

It has effects on the amount of resources we are willing to devote to mental health as opposed to mental health or heart disease.

The Global Burden of Disease Study showed that by 2020 depression is going to be the second leading cause of morbidity across the globe. And yet it receives nowhere near the societal attention, funding, research money that either cancer or cardiac disease do.

“Courtesy stigma,” which is prejudice by association, impacts people in the mental health field who feel they are not given the same respect as people that work in other areas of medicine.

Families, by virtue of having someone in the family with a mental illness, feel that people avoid them.

The stigma also becomes a block between people with mental illness and treatment that could greatly help them, says Rebecca Palpant Shimkets, Assistant Director of the Carter Center Mental Health Program. She has worked alongside former first lady Rosalynn Carter, a longtime advocate for the mentally ill since her days in the White House.

“When we talk about stigma, it’s not just, ‘oh, you know, you carry a mark of shame,’” says Palpant Shimkets. “I don’t think we can talk about stigma without talking about discrimination. There’s that real fear there that if I do seek treatment, what will happen to me. Will I be labeled as crazy, or will it have an impact on my job? Or will my family turn against me? There is deep a connection between stigma and discrimination.” She believes that because of the stigma mental health systems are the first to be sacrificed to budget cuts.

As an expert on stigma, she suggests three keys that can bring us closer to healing stigma:

Media can help. “For the longest time there was only sensational reporting, only around major events that were dramatic that exhibited bizarre behaviors from somebody with a mental illness. And there simply were not stories about recovery and about what mental illnesses truly were and how prevalent they are. We are seeing much, much more of that—but we still have a long way to go.”

Policy Change. “Policy is a solution and an answer in some of those areas. We can’t really change the way people feel but we can say, “It’s wrong to discriminate." We have to have systems that support people in getting the care that they need. Hopefully, as people access more services, they recover, we have systems that work, and that attitudes and hearts will follow.”

Speaking out. “People who have the lived experience of mental illness—via one episode of depression—or somebody living with a chronic condition like schizophrenia need to talk about it. When it feels right for them—come out and talk, and say, this happens to me too. I think that can have a great impact too.”

“I decided that I was not going to be ashamed and that I was going to focus on healing,” she says. “Deciding not to hide my journey of recovering from depression has been the best decision I made. I was absolutely astounded at how many people were going through that same thing that I was, or was close to someone who was. It helped me realize that depression is really common, and that because of fear, we are suffering alone. Being open meant that I could explain my behavior in terms of being ill and getting well, instead of trying to hide what I was going through. “

Dr. Tamar Chansky, a licensed psychologist and author of Freeing Yourself from Anxiety (DaCapo, 2012), says it is also important for those who are not mentally ill to reach in and find our own compassion and understanding. “We see a broken leg and we can relate-- we sense what it would be like to feel that pain and to have trouble walking,” she says. “The anguish that someone experiences from depression, or the limitations on mobility one has with panic, we may think. ‘I don't feel that way-- so why do they.’ But If we think about how any of us feel on a bad day-- and what we would want from others around us-- judgment or understanding-- we see how quickly we can actually relate to the invisible needs and obstacles that someone with a mental illness experiences. We don't want others to judge us or tell us we shouldn't feel the way we do, we want them to either give us space or give us support--this is the key to overcoming stigma.”

Pescosolido, a sociology professor at Indiana University, has been researching stigma since the early nineties and says that the article released today is just the start of looking at how countries around the world deal with mental health issues and the stigma attached.

“I think the important thing, from a public health perspective, is it gives us a real sense of where we have to go in terms of further work to increase acceptance and inclusion,” she says. “And to decrease this tremendous disparity and mortality between people who have mental health issues and those who don’t.”

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